Endosonographie bei chronischer Pankreatitis

Zusammenfassung

In der Diagnostik und Therapieplanung bei chronischer Pankreatitis hat die Endosonographie vor dem Hintergrund der im Vergleich zur ERCP ungleich niedrigeren Komplikationsrate zunehmend an Bedeutung gewonnen, ohne allerdings alle diagnostischen Probleme zu lösen. Aufgrund der sehr hohen diagnostischen Genauigkeit, die sich auf die gleichzeitige Beurteilbarkeit von Parenchym- und Gangkriterien gründet, wird sie von einigen Autoren bereits als neue morphologische Goldstandardmethode gesehen. Voraussetzung für einen breiten Einsatz der Endosonographie als morphologische Goldstandardmethode für die Diagnostik bei chronischer Pankreatitis ist sowohl die Einigung auf einen zur Cambridge-Klassifikation kompatiblen Kriterien- und Graduierungskatalog als auch eine intensive Untersucherausbildung. Die Einordnung endosonographischer isolierter Parenchymkriterien mit Ausnahme von Kalzifikationen als Frühzeichen der chronischen Pankreatitis bedarf allerdings der kritischen Wertung. Schwächen der Methode liegen bei Fragestellungen wie der Abgrenzung von Frühformen der chronischen Pankreatitis gegen Altersveränderungen, Residuen einer akuten Pankreatitis und diffuser alkoholtoxischer Fibrose, der Differenzierung echoarmer Raumforderungen bei chronischer Pankreatitis sowie zystischer Pankreasläsionen, für die die konkurrierenden bildgebenden Methoden allerdings ebenfalls eine unzureichende diagnostische Genauigkeit aufweisen. In der interdisziplinären Planung und Durchführung der Therapie von Pseudozysten, peripankreatischen Nekrosen, Pankreasgangobstruktionen, Gallengangstenosen und Pankreatikolithiasis leistet die Endosonographie allerdings schon heute einen wesentlichen Beitrag.

Abstract

Endoscopic ultrasound has continuously gained importance and has proven to be of clinical value in patients with chronic pancreatitis. In addition, the much lower complication rate when compared to ERCP has to be recognised. Some authors have indicated that endoscopic ultrasound in the evaluation of chronic pancreatitis is the imaging method of choice, depending on both ductal and parenchymal criteria, but there are still some limitations. The two major limitations of EUS preventing it being the “gold standard” in patients with chronic pancreatitis are the lack of standard criteria to be used, and adequate education. Endoscopic ultrasound is difficult to learn and therefore teaching has to be standardised. A general acceptance of the staging of chronic pancreatitis using a catalogue based on criteria compatible to the Cambridge classification is required. Difficulties in evaluating parenchymal criteria with the exception of “indicative” calcifications, depend on the differentiation of the normal ageing process from sequelae of acute pancreatic, ethyl-toxic fibrosis and early stages of chronic pancreatitis. In addition, the differentiation of hypoechoic and cystic lesions as inflammatory changes or neoplastic tumours is still difficult; complementary imaging methods also have low sensitivity in this area. In conclusion, there is no doubt that endoscopic ultrasound has proven to be of value using an interdisciplinary approach in the evaluation and therapy of pseudocysts, peripancreatic necrosis, and pancreatic and bile duct obstruction.

Schlüsselwörter

Review - endoskopischer Ultraschall - Goldstandard - Cambridge-Klassifikation - Ausbildung

Key words

Review - endoscopic ultrasound - gold standard - Cambridge classification - education

• 1 Sahai A V, Mishra G, Penman I D. et al . EUS to detect evidence of pancreatic disease in patients with persistent or nonspecific dyspepsia.  Gastrointest Endosc. 2000;  52 (2) 153-159
• 2 Lankisch P G. Sicherheit bei der Diagnostik der chronischen Pankreatitis: Was ist wirklich erforderlich?.  Dtsch Med Wschr. 2001;  126 96-101
• 3 Lankisch P G, Seidensticker F, Otto J. et al . Secretin-pancreozymin test (SPT) and endoscopic retrograde cholangiopancreatography (ERCP): both are necessary for diagnosing or excluding chronic pancreatitis.  Pancreas. 1996;  12 (2) 149-152
• 4 Forsmark C E. The diagnosis of chronic pancreatitis.  Gastrointest Endosc. 2000;  52 (2) 293-298
• 5 Glasbrenner B, Kahl S, Malfertheiner P. Modern diagnostics of chronic pancreatitis.  Eur J Gastroenterol Hepatol. 2002;  14 (9) 935-941
• 6 Hawes R H. Comparison of diagnostic modalities: EUS, ERCP, and fluid analysis.  Gastrointest Endosc. 1999;  49 (3 Pt 2) S74-S76
• 7 Kahl S, Leodolter A, Glasbrenner B. et al . Chronische Pankreatitis: Bildgebung und Funktionstests.  Chir Gastroenterol. 2001;  17 288-293
• 8 Lankisch P G, Staritz M, Freise J. Reliability of the diagnosis of chronic pancreatitis.  Z Gastroenterol. 1990;  28 (5) 253-258
• 9 Sahai A V. EUS and chronic pancreatitis.  Gastrointest Endosc. 2002;  56 (Suppl 4) S76-S81
• 10 Coyle W J, Pineau B C, Tarnasky P R. et al . Evaluation of unexplained acute and acute recurrent pancreatitis using endoscopic retrograde cholangiopancreatography, sphincter of Oddi manometry and endoscopic ultrasound.  Endoscopy. 2002;  34 (8) 617-623
• 11 Lankisch P G, Assmus C, Maisonneuve P. et al . Epidemiology of pancreatic diseases in Luneburg County. A study in a defined german population.  Pancreatology. 2002;  2 (5) 469-477
• 12 Hernandez L V, Bhutani M S. Endoscopic ultrasound and pancreatic cysts: a sticky situation!.  Am J Gastroenterol. 2001;  96 (12) 3229-3230
• 13 Erk J U, Bunk A, Schentke K U. Die transabdominelle Sonographie in der Diagnostik der chronischen Pankreatitis.  Verdauungskrankheiten. 2000;  15 118-123
• 14 Ikeda M, Sato T, Morozumi A. et al . Morphologic changes in the pancreas detected by screening ultrasonography in a mass survey, with special reference to main duct dilatation, cyst formation, and calcification.  Pancreas. 1994;  9 (4) 508-512
• 15 Jones S N, Lees W R, Frost R A. Diagnosis and grading of chronic pancreatitis by morphological criteria derived by ultrasound and pancreatography.  Clin Radiol. 1988;  39 (1) 43-48
• 16 Lees W R, Vallon A G, Denyer M E. et al . Prospective study of ultrasonography in chronic pancreatic disease.  Br Med J. 1979;  1 (6157) 162-164
• 17 Dietrich C F, Becker D. Signalverstärkte Farbdopplersonographie des Abdomens. Konstanz; Schnetztor-Verlag GmbH 2002
• 18 Dorffel T, Wruck T, Ruckert R I. et al . Vascular complications in acute pancreatitis assessed by color duplex ultrasonography.  Pancreas. 2000;  21 (2) 126-133
• 19 Hollerbach S, Ruser J, Ochs A. et al . Current status of abdominal pancreatic ultrasound. A retrospective analysis of 585 pancreatic ultrasound examinations.  Med Klin (Munich). 1994;  89 (1) 7-13
• 20 Hawes R H, Zaidi S. Endoscopic ultrasonography of the pancreas.  Gastrointest Endosc Clin N Am. 1995;  5 (1) 61-80
• 21 Vilmann P, Hancke S. Endoscopic ultrasound scanning of the upper gastrointestinal tract using a curved linear array transducer: „the linear anatomy”.  Gastrointest Endosc Clin N Am. 1995;  5 (3) 507-521
• 22 Chang K J, Erickson R A. A primer on linear array endosonographic anatomy.  Gastrointest Endosc. 1996;  43 (2 Pt 2) S43-S47
• 23 Savides T J, Gress F G, Zaidi S A. et al . Detection of embryologic ventral pancreatic parenchyma with endoscopic ultrasound.  Gastrointest Endosc. 1996;  43 (1) 14-19
• 24 Wiersema M J, Wiersema L M. Endosonography of the pancreas: normal variation versus changes of early chronic pancreatitis.  Gastrointest Endosc Clin N Am. 1995;  5 (3) 487-496
• 25 Wiersema M J, Hawes R H, Lehman G A. et al . Prospective evaluation of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in patients with chronic abdominal pain of suspected pancreatic origin.  Endoscopy. 1993;  25 (9) 555-564
• 26 Catalano M F, Lahoti S, Geenen J E. et al . Prospective evaluation of endoscopic ultrasonography, endoscopic retrograde pancreatography, and secretin test in the diagnosis of chronic pancreatitis.  Gastrointest Endosc. 1998;  48 (1) 11-17
• 27 Sahai A V, Zimmerman M, Aabakken L. et al . Prospective assessment of the ability of endoscopic ultrasound to diagnose, exclude, or establish the severity of chronic pancreatitis found by endoscopic retrograde cholangiopancreatography.  Gastrointest Endosc. 1998;  48 (1) 18-25
• 28 Lai R, Wiersema M J, Sahai A V. et al . Blinded comparison of linear and radial endoscopic ultrasound (EUS) for the evaluation of chronic pancreatitis.  Gastrointest Endosc. 2001;  53 AB 170, abstract 4208
• 29 Wallace M B, Hawes R H, Durkalski V. et al . The reliability of EUS for the diagnosis of chronic pancreatitis: interobserver agreement among experienced endosonographers.  Gastrointest Endosc. 2001;  53 (3) 294-299
• 30 Wallace M B, Affi A, Eloubeidi M A. et al . How much experience is required to correctly interprete EUS features of chronic ancreatitis? A multicenter prospective trial of third tier EUS trainees compared to a consensus of experts.  Gastrointest Endosc. 2000;  51 AB 176, abstract 4589
• 31 Buscail L, Escourrou J, Moreau J. et al . Endoscopic ultrasonography in chronic pancreatitis: a comparative prospective study with conventional ultrasonography, computed tomography, and ERCP.  Pancreas. 1995;  10 (3) 251-257
• 32 Giovannini M, Seitz J F. Endoscopic ultrasonography with a linear-type echoendoscope in the evaluation of 94 patients with pancreatobiliary disease.  Endoscopy. 1994;  26 (7) 579-585
• 33 Kahl S, Glasbrenner B, Leodolter A. et al . EUS in the diagnosis of early chronic pancreatitis: a prospective follow-up study.  Gastrointest Endosc. 2002;  55 (4) 507-511
• 34 Hollerbach S, Klamann A, Topalidis T. et al . Endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA) cytology for diagnosis of chronic pancreatitis.  Endoscopy. 2001;  33 (10) 824-831
• 35 Nattermann C, Goldschmidt A J, Dancygier H. Endosonography in chronic pancreatitis-a comparison between endoscopic retrograde pancreatography and endoscopic ultrasonography.  Endoscopy. 1993;  25 (9) 565-570
• 36 Nattermann C, Goldschmidt A J, Dancygier H. Endosonography in chronic pancreatitis. A comparative study of endoscopic retrograde pancreatography and endoscopic sonography.  Ultraschall Med. 1992;  13 (6) 263-270
• 37 Dancygier H. Endoscopic ultrasonography in chronic pancreatitis.  Gastrointest Endosc Clin N Am. 1995;  5 (4) 795-804
• 38 Wallace M B, Hawes R H. Endoscopic ultrasound in the evaluation and treatment of chronic pancreatitis.  Pancreas. 2001;  23 (1) 26-35
• 39 Wiersema M J. Diagnosing chronic pancreatitis: shades of gray.  Gastrointest Endosc. 1998;  48 (1) 102-106
• 40 Bhutani M S. Endoscopic ultrasonography: changes of chronic pancreatitis in asymptomatic and symptomatic alcoholic patients.  J Ultrasound Med. 1999;  18 (7) 455-462
• 41 Hastier P, Buckley M J, Francois E. et al . A prospective study of pancreatic disease in patients with alcoholic cirrhosis: comparative diagnostic value of ERCP and EUS and long-term significance of isolated parenchymal abnormalities.  Gastrointest Endosc. 1999;  49 (6) 705-709
• 42 Rajan E, Clain J E, Levy M J. et al . Prospectiv evaluation of age - related changes of the pancreas identified by endosonography.  Gastrointest Endosc. 2002;  55 AB 95, abstract 577
• 43 Jafri S F, Muthusamy R, Hernandez M. et al . Prospective prevalence of endoscopic ultrasound (EUS) criteria for chronic pancreatitis (CP) in patients undergoing routine upper EUS.  Gastrointest Endosc. 2001;  53 AB 168, abstract 4201
• 44 Snady H. Endoscopic ultrasonography in benign pancreatic disease.  Surg Clin North Am. 2001;  81 (2) 329-344
• 45 Lambert R, Caletti G, Cho E. et al . International Workshop on the clinical impact of endoscopic ultrasound in gastroenterology.  Endoscopy. 2000;  32 (7) 549-584
• 46 Tandon M, Topazian M. Endoscopic ultrasound in idiopathic acute pancreatitis.  Am J Gastroenterol. 2001;  96 (3) 705-709
• 47 Ainsworth A P, Mortensen M B, Durup J. et al . Clinical impact of endoscopic ultrasonography at a county hospital.  Endoscopy. 2002;  34 (6) 447-450
• 48 Wiersema M J, Chak A, Kopecky K K. et al . Duplex Doppler endosonography in the diagnosis of splenic vein, portal vein, and portosystemic shunt thrombosis.  Gastrointest Endosc. 1995;  42 (1) 19-26
• 49 Bhutani M S, Hoffman B J, Van Velse A. et al . Contrast-enhanced endoscopic ultrasonography with galactose microparticles: SHU508 A (Levovist).  Endoscopy. 1997;  29 (7) 635-639
• 50 Seifert H, Schmitt T, Dietrich C F. et al . Visualization of the distal common bile duct by extraductal endoscopic ultrasound using transendoscopic miniprobes.  Gastrointest Endosc. 2000;  51 AB 166, abstract 4554
• 51 Canto M I, Chak A, Stellato T. et al . Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis.  Gastrointest Endosc. 1998;  47 (6) 439-448
• 52 Palazzo L, O'toole D. EUS in common bile duct stones.  Gastrointest Endosc. 2002;  56 (Suppl 4) S49-S57
• 53 Prat F, Amouyal G, Amouyal P. et al . Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common-bileduct lithiasis.  Lancet. 1996;  347 (8994) 75-79
• 54 Seifert H, Wehrmann T, Hilgers R. et al . Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities.  Gastrointest Endosc. 2004;  60 61-67
• 55 Kohut M, Nowakowska-Dulawa E, Marke T. et al . Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones.  Endoscopy. 2002;  34 (4) 299-303
• 56 Lachter J, Rubin A, Shiller M. et al . Linear EUS for bile duct stones.  Gastrointest Endosc. 2000;  51 (1) 51-54
• 57 Frossard J L, Sosa-Valencia L, Amouyal G. et al . Usefulness of endoscopic ultrasonography in patients with „idiopathic” acute pancreatitis.  Am J Med. 2000;  109 (3) 196-200
• 58 Lowenfels A B, Maisonneuve P, Cavallini G. et al . Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group.  N Engl J Med. 1993;  328 (20) 1433-1437
• 59 Talamini G, Falconi M, Bassi C. et al . Incidence of cancer in the course of chronic pancreatitis.  Am J Gastroenterol. 1999;  94 (5) 1253-1260
• 60 Parasher G, Alasadi R, Chang K J. et al . Endoscopic ultrasound (EUS) changes of chronic pancreatitis (CP) are common among patients with pancreatic cancer.  Gastrointest Endosc. 2002;  55 AB 250, abstract W 1560
• 61 Baron P L, Aabakken L E, Cole D J. et al . Differentiation of benign from malignant pancreatic masses by endoscopic ultrasound.  Ann Surg Oncol. 1997;  4 (8) 639-643
• 62 Barthet M, Portal I, Boujaoude J. et al . Endoscopic ultrasonographic diagnosis of pancreatic cancer complicating chronic pancreatitis.  Endoscopy. 1996;  28 (6) 487-491
• 63 Brand B, Pfaff T, Binmoeller K F. et al . Endoscopic ultrasound for differential diagnosis of focal pancreatic lesions, confirmed by surgery.  Scand J Gastroenterol. 2000;  35 (11) 1221-1228
• 64 Nattermann C, Goldschmidt A J, Dancygier H. Endosonography in the assessment of pancreatic tumors. A comparison of the endosonographic findings of carcinomas and segmental inflammatory changes.  Dtsch Med Wochenschr. 1995;  120 (46) 1571-1576
• 65 Roesch T, Lorenz R, Braig C. et al . Endoscopic ultrasound in pancreatic tumor diagnosis.  Gastrointest Endosc. 1991;  37 (347) 352
• 66 Ozawa Y, Numata K, Tanaka K. et al . Contrast-enhanced sonography of small pancreatic mass lesions.  J Ultrasound Med. 2002;  21 (9) 983-991
• 67 Rickes S, Unkrodt K, Neye H. et al . Differentiation of pancreatic tumours by conventional ultrasound, unenhanced and echo-enhanced power Doppler sonography.  Scand J Gastroenterol. 2002;  37 (11) 1313-1320
• 68 Rickes S, Unkrodt K, Ocran K. et al . Evaluation of doppler ultrasonography criteria for the differential diagnosis of pancreatic tumors.  Ultraschall Med. 2000;  21 (6) 253-258
• 69 Hirooka Y, Goto H, Ito A. et al . Contrast-enhanced endoscopic ultrasonography in pancreatic diseases: a preliminary study.  Am J Gastroenterol. 1998;  93 (4) 632-635
• 70 Kato T, Tsukamoto Y, Naitoh Y. et al . Ultrasonographic and endoscopic ultrasonographic angiography in pancreatic mass lesions.  Acta Radiol. 1995;  36 (4) 381-387
• 71 Becker D, Strobel D, Bernatik T. et al . Echo-enhanced color- and power-Doppler EUS for the discrimination between focal pancreatitis and pancreatic carcinoma.  Gastrointest Endosc. 2001;  53 (7) 784-789
• 72 Ueno N, Tomiyama T, Tano S. et al . Utility of endoscopic ultrasonography with color Doppler function for the diagnosis of islet cell tumor.  Am J Gastroenterol. 1996;  91 (4) 772-776
• 73 Wiersema M J, Vilmann P, Giovannini M. et al . Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment.  Gastroenterology. 1997;  112 (4) 1087-1095
• 74 Williams D B, Sahai A V, Aabakken L. et al . Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience.  Gut. 1999;  44 (5) 720-726
• 75 Catalano M F, Fazel A, Quadri A. et al . Factors that influence accuracy of tissue sampling in pancreatic mass lesions: An EUS - FNA study.  Gastrointest Endosc. 2002;  55 AB 246, abstract W 1548
• 76 Canto M I, Smith C L, McCelland L. et al . Tumor versus Pseudotumor? A prospektive study of factors associated with missed cancers and nondiagnostic EUS-FNA in patients with pancreaticobiliary lesions.  Gastrointest Endosc. 2000;  51 AB 170, abstract 4566
• 77 Fritscher-Ravens A, Brand L, Knofel W T. et al . Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis.  Am J Gastroenterol. 2002;  97 (11) 2768-2775
• 78 Brugge W R. The role of EUS in the diagnosis of cystic lesions of the pancreas.  Gastrointest Endosc. 2000;  52 (Suppl 6) S18-S22
• 79 Martin I, Hammond P, Scott J. et al . Cystic tumours of the pancreas.  Br J Surg. 1998;  85 (11) 1484-1486
• 80 Sedlack R, Affi A, Vazquez-Sequeiros E. et al . Utility of EUS in the evaluation of cystic pancreatic lesions.  Gastrointest Endosc. 2002;  56 (4) 543-547
• 81 Seifert H, Faust D, Schmitt T. et al . Transmural drainage of cystic peripancreatic lesions with a new large-channel echo endoscope.  Endoscopy. 2001;  33 (12) 1022-1026
• 82 Koito K, Namieno T, Nagakawa T. et al . Solitary cystic tumor of the pancreas: EUS-pathologic correlation.  Gastrointest Endosc. 1997;  45 (3) 268-276
• 83 Ahmad N A, Kochman M L, Lewis J D. et al . Can EUS alone differentiate between malignant and benign cystic lesions of the pancreas?.  Am J Gastroenterol. 2001;  96 (12) 3295-3300
• 84 Brandwein S L, Farrell J J, Centeno B A. et al . Detection and tumor staging of malignancy in cystic, intraductal, and solid tumors of the pancreas by EUS.  Gastrointest Endosc. 2001;  53 (7) 722-727
• 85 Brugge W R, Saltzman J R, Scheiman J M. et al . Diagnosis of cystic neoplasms of the pancreas by EUS: The report of the cooperative pancreatic cyst study.  Gastrointest Endosc. 2001;  53 AB 71 (abstract)
• 86 Sand J A, Hyoty M K, Mattila J. et al . Clinical assessment compared with cyst fluid analysis in the differential diagnosis of cystic lesions in the pancreas.  Surgery. 1996;  119 (3) 275-280
• 87 Ikeda M, Sato T, Ochiai M. et al . Ultrasonographic follow-up study of small pancreatic cysts of unknown etiology.  Bildgebung. 1993;  60 (4) 209-214
• 88 Lai R, Stanley M W, Bardales R. et al . Endoscopic ultrasound-guided pancreatic duct aspiration: diagnostic yield and safety.  Endoscopy. 2002;  34 (9) 715-720
• 89 Fockens P. EUS in drainage of pancreatic pseudocysts.  Gastrointest Endosc. 2002;  56 (Suppl 4) S93-S97
• 90 Fockens P, Johnson T G, van Dullemen H M. et al . Endosonographic imaging of pancreatic pseudocysts before endoscopic transmural drainage.  Gastrointest Endosc. 1997;  46 (5) 412-416
• 91 Seifert H, Dietrich C, Schmitt T. et al . Endoscopic ultrasound-guided one-step transmural drainage of cystic abdominal lesions with a large-channel echo endoscope.  Endoscopy. 2000;  32 (3) 255-259
• 92 Gress F, Ikenberry S, Sherman S. et al . Endoscopic ultrasound-directed pancreatography.  Gastrointest Endosc. 1996;  44 (6) 736-739
• 93 Wiersema M J, Sandusky D, Carr R. et al . Endosonography-guided cholangiopancreatography.  Gastrointest Endosc. 1996;  43 102-106
• 94 Will U, Zinsser E, Bosseckert H. Die Endosonographie in der Diagnostik der chronischen Pankreatitis.  Verdauungskr. 1997;  15 137-142
• 95 Gress F, Gottlieb K, Cummings O. et al . Endoscopic ultrasound characteristics of mucinous cystic neoplasms of the pancreas.  Am J Gastroenterol. 2000;  95 (4) 961-965
• 96 Das A, Sivak M V Jr, Chak A. Cervical esophageal perforation during EUS: a national survey.  Gastrointest Endosc. 2001;  53 (6) 599-602
• 97 Eloubeidi M A, Chen V K, Eltoum I A. et al . Endoscopic ultrasound-guided fine needle aspiration biopsy of patients with suspected pancreatic cancer: diagnostic accuracy and acute and 30-day complications.  Am J Gastroenterol. 2003;  98 (12) 2663-2668
• 98 Dietrich C F, Gouder S, Hocke M. et al . Endosonographie der Choledocholithiasis und ihrer Differentialdiagnosen.  Endoskopie Heute. 2004;  17 160-166
• 99 Frossard J L, Amouyal P, Amouyal G. et al . Performance of endosonography-guided fine needle aspiration and biopsy in the diagnosis of pancreatic cystic lesions.  Am J Gastroenterol. 2003;  98 (7) 1516-1524
• 100 Dietrich C F. Endoskopischer Ultraschall - Eine Einführung. Konstanz; Schnetztorverlag 2005, in press